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SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Mark Crum 909-972-7581 <br />C <br />Facility Name Pilot -Flying J #617 <br />Phone # 209-339-4066 <br />I <br />L <br />Address 15100 N. Thornton Road Lodi, CA 95242 <br />1 <br />T <br />Cross Street Thornton and Highway 12 <br />Y <br />Owner/Operator Pilot Travel Centers LLC <br />Phone # 864-474-2421 <br />c <br />O <br />Contractor Name Jones Covey Group, Inc. <br />Phone # 909-972-7581 <br />NCOntractOr <br />T <br />Address 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 <br />CA Lic # 804431 Class A, B, HAZ <br />R <br />A <br />Insurer IOA Insurance Services <br />Work Comp # WC2888057 <br />C <br />T <br />ICC Technician's Name Fabian Gomez #5246134 <br />Expiration Date 6/12/2011 <br />o <br />R <br />ICC Installer's Name Fabian Gomez <br />Expiration Date <br />Tank system work area <br />1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC etc.) <br />T <br />20,000 <br />Diesel <br />2001 Double Wall <br />A <br />20,000 <br />Diesel <br />2001 Double Wall <br />N <br />K <br />20,000 <br />Diesel <br />2001 Double Wall <br />20,000 <br />Regular <br />2001 Double Wall <br />12,000 <br />Premium <br />2001 Double Wall <br />P <br />Approved Approved with conditions Disapproved <br />L <br />(See Attachment With Conditions <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Compliance 10/7/2010 <br />Applicant's Signature Title Environmental Data <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />NAME Holly Mendez TITLE Environmental Compliance PHONE * 909-972-7581 <br />ADDRESS 9595 Lucas Ranch Road #100 Rancho Cucamonga, CA 91730 <br />SIGNATURE `� v v `� DATE 10/7/2010 <br />EH230038 (revised 07/22/10) <br />